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Hooked

I walked into the room of a dying man. This phrase might conjure up the image of a frail, white-haired patient peacefully nearing the end of life. Alex, however, was thirty--just two years older than me.

I was a third-year medical student doing a rotation in the ICU. This first encounter was sadly inglorious: As my team entered Alex's room, the police officer who'd been guarding him walked out, leaving Alex handcuffed to the bed.

Alex looked like a ghost, his cheeks sunken and lifeless. A heart infection caused by his IV drug use was spewing dangerous bacteria through his bloodstream, infecting his lungs and spine. When not sedated, he was delirious, eyes staring wildly between wasted temples.

The day after, Alex's mother came into the hospital. She was conservatively dressed, her only jewelry a small gold cross around her neck. The hard, worn angles of her face framed soft eyes and a broad smile. She had discovered Alex's whereabouts by calling the local jails, knowing that he'd either be there or in the hospital or on the streets.

With Alex's brother--a former addict himself--she returned the next day to talk with the palliative-care team. They asked her to decide whether they should pursue further treatment options for Alex. (None were expected to save him.) She cried, but having lived through other close calls with Alex, she understood how dire his situation was.

She told us of Alex's childhood growing up in a churchgoing middle-class family, of his charming personality and large circle of friends, of his creativity as a landscaper. She showed us photos: Alex as a middle schooler in a baseball uniform, as a young man in a suit at a family reunion, and standing before a finished bar that he'd constructed. And she described his current life: an apartment with a needle-strewn carpet, a barren refrigerator and feces-smeared floors.

"Alex was the heart of our family, but I don't know if he has that spirit anymore," she finished resignedly. "I know this might be his time." It was decided to continue, but not escalate, his treatment regimen.

In the days that followed, I found myself deeply interested in Alex. Earlier I had worked with a palliative-care team treating elderly patients. Now I realized that, as heart-wrenching as I had found those experiences, the age difference had buffered my distress.

Treating Alex shattered those boundaries. Seeing him in his hospital bed, I'd feel a surge of protest: This young man isn't supposed to be dying! Alex's youth and vulnerability forced me to reflect on my own; I felt any sense of invincibility I might possess ebbing away.

Amazingly, Alex managed to survive. He was moved to a rehabilitation unit within the hospital. Over several weeks, I came to know him better. Although no longer on his treatment team, I wanted to witness his emotional and physical recovery.

"I started drinking and smoking weed in high school," he told me. "But my life didn't get so fucked up until I started taking pills."

He had been through many rehab facilities--and even a two-year stint of sobriety. He showed me pictures of himself speaking at a national addiction conference.

"I know this sounds crazy now, but I was the one telling other addicts how to stop using," he said.

I realized that the opiate epidemic has created a new clinical landscape: ICU beds once devoted to older patients now hold patients my age. As a result, medical trainees like me must interact with, and treat, our dying peers.

Talking with Alex, I was struck not by the differences in our lives but by the similarities. Growing up, we both played soccer, attended private and public schools and (to our parents' annoyance) fought with our older siblings.

We discussed everything from politics to dating to job prospects--the same conversations I have every day with my peers. Once, we sat in his room and watched NCAA basketball; he cheered on the Virginia Cavaliers while I rooted for my UNC Tar Heels. My relationship with Alex was familiar, even intimate. Only the disposable gown and latex gloves that I donned before entering his room reminded me that we were sitting not in a den or sports bar but in a hospital room.

There were other similarities. Like many my age, I had experimented with marijuana. Now I wondered what had kept me and my friends from following Alex's path. Among our peers, opioid pills didn't carry the same stigma as cocaine or heroin: After all--irony of ironies--they were prescribed by doctors! I remembered a friend's excitedly describing the opioid prescription he'd received after having his wisdom teeth removed. I recalled parties where "oxy" was passed around, and how, after my friends' visit, the Vicodin was missing from my father's medicine cabinet. It was painfully easy to imagine any of us in Alex's place.

A month after Alex was admitted, I finished my rotation. On my last day, I went to say goodbye. His chest tube had been removed, his face had filled out, and he was regaining strength. He resembled his youthful photographs.

"John, I can't wait to get out of here," he said. "I want to go back to Virginia, away from my old life here. If I can just stay near my family, I can keep clean and start working construction jobs again."

We hugged, and I promised to look him up the next time I was in town.

A year later, while considering my upcoming rotations, I thought of Alex. After trying unsuccessfully to get in touch with him, I did an internet search. The results were unsurprising, but devastating. Under two old arrest reports, I saw Alex's obituary.

"In our memory he survives," it ended.

It was hard to reconcile the memory of Alex as I last saw him--cheerful, strong, hopeful--with the knowledge that he had succumbed to his addiction. Although I knew that it is common for people with his history to relapse, our personal connection had led me to regard him, naively, as a special case. His death reinforced addiction's power to overwhelm even the strongest resolutions.

Despite Alex's bleak end, knowing him has left me feeling positive about the future of the opioid epidemic. Much as the HIV/AIDS epidemic galvanized a generation of physicians to combat it because of its devastating impact on young people, my experience with Alex has left me feeling a deep responsibility to help others like him.

I used to see pain management as a secondary goal, almost as grunt work, rather than as a central part of care. Now I'm conscious of the repercussions of mismanaged or inattentive care for pain. I ask how a patient's pain is--not to check off a required question but to see what can be done to lessen or remove opioids from the regimen. I will carry these practices into residency and beyond.

I believe that many of my peers will share my goals, and that our generation of physicians will be energized to pursue more effective treatments for addiction and to make the opioid epidemic a thing of the past.

In this way, and through my connection to other patients like him, I hope to help Alex live on.

About the author:

John Barber, a medical student at the University of North Carolina at Chapel Hill, is taking two years off between his third and fourth years to conduct basic science research in Leuven, Belgium. "My interest in writing stems from my love of reading, but my specific interest in narrative medicine came about through the strong humanities curriculum at the UNC School of Medicine--Asheville campus."

Comments

Unfortunately, the illegal use of opiates has led to the same conclusion this young doctor made. I have friends in tremendous pain who are being denied medications because of this problem. It’s like with any other addiction. Treat the addict and treat the pain patient. Two different issues. Addiction is a difficult disease. It could be any drug. My heart breaks that he relapsed, though, and died.

I’m so sorry once again to read the conclusion that comes out of the acceptance of an incorrect assumption. The cause of the opiate crisis is illicit fentanyl from other countries, not prescribed opiates from the USA. This young physician is celebrating his conversion to a new “central part of care”, better management of care for pain as he calls it. And yet as a chronic pain patient I know he is not managing pain but denying access to certain medications for pain for severe long term pain when other effective treatments do not yet exist. His choice fails to keep opiate abusers alive while trading for unbearable pain and suicide in those following the rules of responsible medical treatment for severe chronic pain. How sad to make such a destructive mistake when the clear intent of his heart is so good.